Strategies to identify and influence persons at increased risk
for infection with human immunodeficiency virus (HIV) and other
sexually transmitted diseases (STDs) require outreach to provide
prevention messages directly to persons at risk, assist them to
obtain prevention services, and encourage them to reduce risks.
Street outreach programs complement CDC's information and education
campaign "America Responds to AIDS" by providing persons with
specific risk-reduction messages and materials (1). This report
describes efforts to implement such approaches in Colorado Springs,
Colorado, and presents preliminary results regarding the prevalence
of Neisseria gonorrhoeae and Chlamydia trachomatis infections among
female street prostitutes in that community.

Since 1969, women who identified themselves or were referred
to the health department as prostitutes in Colorado Springs (El
Paso County) have been offered voluntary screening for gonorrhea
and syphilis (2,3). From 1970 through 1986, 19% of specimens
cultured for N. gonorrhoeae were positive; 20 cases of syphilis
were also diagnosed. In June 1985, screenings were augmented by
voluntary counseling and testing for HIV antibody and in June 1987
for C. trachomatis.

In 1987, after a cross-sectional study established the
prevalence of HIV and other STDs in 98 prostitutes (4), the El Paso
County Health Department began an intensive program of
risk-reduction counseling and condom distribution for female
prostitutes in Colorado Springs. Health workers visited sites where
prostitutes congregate to 1) present and reinforce messages about
STDs and HIV infection prevention, 2) encourage prostitutes and
their sex partners to visit the local health department clinic for
HIV-antibody testing and screening for other STDs, 3) refer drug
users to local drug-treatment programs, and 4) dispense free
condoms and bottles of bleach (for injecting-drug users (IDUs) to
use in cleaning needles and syringes). On average, one worker spent
approximately 1 hour per day in the field, spoke with approximately
five prostitutes per day, and distributed approximately 300 condoms
per week.

In 1990, the prevalence of N. gonorrhoeae infections among
prostitutes declined substantially and remained lower in 1991
(Table 1). An analysis based on a logistic regression model (5)
suggested that the prevalence of both N. gonorrhoeae and C.
trachomatis infections in 118 different prostitutes was inversely
related to frequency of testing. When an adjustment was made in the
model for the effect of the year of testing, 32 prostitutes who
were tested five or more times were significantly less likely to be
infected with N. gonorrhoeae than 86 prostitutes who were tested
less frequently (odds ratio=0.2; 95% confidence interval=0.1-0.6).

From 1987 to 1990, reported cases of gonorrhea among
prostitutes, their sex partners, and all others in Colorado Springs
declined 16%, from 1001 cases to 840 cases. From 1987 through 1990,
three cases of early syphilis were diagnosed among prostitutes. Of
252 prostitutes tested for HIV antibody from 1985 through 1990, 11
(4.4%) were positive; of the 10 interviewed, nine were IDUs.

Editorial Note

Editorial Note: The increased risk for gonorrhea and other STDs
among prostitutes reflects their increased exposure to infected sex
partners. In Colorado Springs, street outreach, the active
distribution of condoms, and repeated testing and counseling to
reinforce risk-reduction messages were key components of the
program initiated in 1987 to promote the proper and consistent use
of condoms to prevent sexual transmission of HIV. Although direct
measures of condom use are unavailable, the recent decline in
gonorrhea may indicate, in part, increased condom use by sex
partners of prostitutes.

The more than 2-year period between implementation of the
outreach program and the decline in the prevalence of gonorrhea may
reflect gradual changes in attitudes and behaviors among
prostitutes that were associated with increasing interaction with
health-care workers. One possibility for the decline in the number
of infections with N. gonorrhoeae could be that more proper and
consistent condom use occurred among prostitutes and their sex
partners. However, neither attitude nor
behavior changes were measured directly. Other factors that may
have affected the decrease in gonorrhea among prostitutes are
unknown.

In New York City (6) and Kinshasa, Zaire (7), shifts in
attitudes and behaviors followed the implementation of similar
programs to promote condom use in targeted populations. However,
because the program in Colorado Springs was not conducted as part
of a randomized trial with control communities, the effectiveness
of outreach, message reinforcement, and repeated testing could not
be rigorously evaluated. Nevertheless, in Denver (approximately 60
miles (100 km) north of Colorado Springs), infections with N.
gonorrhoeae among STD clinic patients declined 21% (8), but
infections with N. gonorrhoeae among prostitutes fluctuated.

Street outreach programs such as the one described in this
report must be evaluated rigorously by state and local health
departments, community-based organizations, and CDC. Future
outreach evaluations should assess behavior changes in IDUs not in
treatment and young persons at high risk for HIV infection and
other STDs.

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